A Review of BPPV & Vestibular RehabilitationBy: Steven Ferro, SPTRutgers University-SouthClinical Education IIIBSR Physical Therapy

Outline● Introduction & Examination.● History Taking & Red Flags.● Differential Diagnosis.● Central vs. Peripheral Signs.

● Diagnostic Criteria for BPPV.○ Posterior Canal○ Lateral Canal

● Treatment Options.● Outcome Measures.● Case Study.● Lab Breakout.

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Objectives1. The physical therapist will demonstrate a better

understanding of the:a. Clinical practice guidelines as described by Bhattacharyya et al. for

benign paroxysmal positional vertigo (BPPV).

b. Intervention strategies for treating both peripheral and central vestibular dysfunction.

c. Signs associated with both peripheral and central vestibular dysfunction.

Introduction & Examination

Introduction● Dizziness accounts for the primary complaint that

necessitates 5.6 million clinic visits (PT) in the United States per year (Wahlgren et al., 2012).

● Of these patients with vertigo, between 17% and 42% received a diagnosis of benign paroxysmal positional vertigo or BPPV (Wahlgren et al., 2012).

Introduction● Dizziness & fear of falling→ decrease in activity→sedentary→

decreased ROM, endurance, & strength→unable to do the

things they used to→social isolation→depression.

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Detailed History● When did first episode occur?

○ What activities was the pt doing?

● Was there spontaneous onset or associated trauma?● Is there any hearing loss or tinnitus?● Are there any triggers that bring on the symptoms?

○ Increases in stress, panic attacks, specific head positions.

● What is the length of symptoms? Frequency?● Any neurologic/cardiac examinations?● Any imaging studies? (MRI)

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Examination Procedures● Subjective Questionnaire (DHI, Vestibular ADL Scale)● Vital Signs● Ocular Examination Including Assessment of Vision

○ Peripheral vs. Central Signs○ Cranial Nerve Screen○ Snellen Eye Examination Chart

● Upper/Lower Quarter Screen● Balance and Gait Assessment● Proprioception and Sensation● Strength and Cervical/Thoracic AROM

(Kisner et al., 2012)

Things to Consider● Vertebrobasilar

insufficiency

● Cervical stenosis● Severe kyphoscoliosis● Limited cervical range of

motion● Severe RA

● Cervical radiculopathies● Paget’s disease● Ankylosing spondylitis● Low back dysfunction● Spinal cord injuries● Morbid obesity● Down syndrome

(Wahlgren et al., 2012)

Central vs. Peripheral

Signs of Central Origin● Purely Vertical nystagmus with Dix-Hallpike ● Direction-changing nystagmus without position changes.● Resting nystagmus ● Neurological symptoms (gait & speech dysfunction) ● Vascular complications in history (Potentially)● Central nystagmus typically is nonfatiguing and vertical ● Presence of saccades (always a central sign)

Listings Cited from: Baloh, 1998 & Bhattacharyya et al., 2008

Signs of Peripheral Origin● More common to have unilateral hearing loss● Prior trauma or infection involving the ear. ● No neurologic symptoms or signs● Fatigable, torsional positional nystagmus● Does not have Saccades

Listings Cited from: Baloh, 1998 & Bhattacharyya et al., 2008

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Saccade Testing

https://www.youtube.com/watch?v=P6uTlnyNaTs

Eye Movements

https://www.youtube.com/watch?v=gyvSmTlGu2k

Diagnostic Criteria: BPPV

Clinical Practice Guideline: BPPV● Posterior canal BPPV: 85 to 95% of BPPV cases● Lateral (horizontal) canal BPPV: 5 and 15%.

○ 2% to 5% (Oron et al., 2015).

● Anterior canal BPPV: Extremely rare (Not covered)● Other rare variations include multiple canal BPPV, and

bilateral multiple canal BPPV.

(Bhattacharyya et al., 2008)

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Diagnostic Criteria: Posterior Canal BPPV

Diagnostic Criteria: Posterior Canal BPPV● Pt reports vertigo with change in head positions

○ Described by the patient as a rotational or spinning sensation ○ Rolling over in bed, tilting the head back, and/or bending forward.

● Vertigo associated with nystagmus with Dix-Hallpike ○ Sensitivity: 82%○ Specificity: 71% (Gold Standard-Posterior Canal)

● Latency period after completion of Dix-Hallpike and onset of symptoms ( 5 to 20 seconds)

(Bhattacharyya et al., 2008)

Diagnostic Criteria: Posterior Canal BPPV● Nystagmus typically fatigues (a reduction in severity of

nystagmus) when the maneuver is repeated.○ Fatigability of the nystagmus as a diagnostic criterion not included.

● Nystagmus: mixed torsional and vertical movement ● Dix-Hallpike may be bilaterally positive● No hearing loss

(Bhattacharyya et al., 2008)

Diagnostic Criteria: Horizontal Canal BPPV

Diagnostic Criteria: Lateral Canal BPPV● If the patient has a history compatible with BPPV and the

Dix-Hallpike test is negative. ● Symptoms of lateral canal BPPV are indistinguishable

from posterior canal BPPV○ Horizontal Nystagmus

● + Supine Roll Test○ Sensitivity and specificity of the supine roll test have not

been determined.

(Bhattacharyya et al., 2008)

Diagnostic Criteria: Supine Roll Test● Rotation to the pathological side causes a very intense

horizontal nystagmus beating toward the undermost (affected)

● Affected side produces the most intense nystagmus(Bhattacharyya et al., 2008)

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Diagnostic Criteria: Supine Roll Test

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Supine Roll Test

Diagnostic Criteria: Lateral Canal BPPV● Geotropic Nystagmus

○ Beats toward the undermost ear during Supine Roll Test○ Indicates Canalolithiasis○ Nystagmus appears after a short duration and last less than 60 seconds

with fatigue.

● Apogeotropic Nystagmus○ Beats away from the undermost ear during Supine Roll Test○ Indicates Cupulolithiasis○ Nystagmus more than 1 minute and does not fatigue.

(Oron et al., 2015)

Diagnostic Criteria: Bow & Lean Test● Canalithiasis (Geotropic):

○ Beats towards the affected ear in the Bow Position.

● Cupulolithiasis (Apogeotropic): ○ Beats towards the affected ear in the Lean Position.

● Patients bow their heads over 90 to 120 degrees (bowing nystagmus) and leaned their heads backward over 45 to 60 degrees (leaning nystagmus) in a sitting position.

(Lee et al., 2010)

(Lee et al., 2010)

Diagnostic Criteria: Bow & Lean Test● Choung et al. evaluated the efficiency of the Bow & Lean

Test in 26 patients with lateral canal BPPV. ○ 10/26 patients patients did not show a prominent ear in the Supine Roll

Test method. ○ 3/10 were unable to be determined by BLT & 7/10 demonstrated different

affected ears when administered the BTL compared to Roll Test. ○ Take Home Point: More work needs to be done

(Choung et al., 2006)

Treatment & Intervention Strategies

Intervention Strategies● There is insufficient evidence from high-quality

randomized controlled studies to evaluate that one strategy is better than another.

● Individualized and supervised protocols have better outcomes yet simple home-based programs can also be effective.

(Eleftheriadou et al., 2012)

Intervention Strategies● Habituation ● Substitution ● Adaptation● Canalith Repositioning

Maneuver (Epley)● Balance Training● Gait Training

(Eleftheriadou et al., 2012)

● Proprioceptive Exercises

● Deep Relaxation ● General Conditioning● Postural corrective

exercises

Intervention Strategies● Adaptation: Disadvantage the visual and somatosensory

systems making the vestibular system work harder. (Umphred, 2013)

● Habituation: Repeated exposure to symptom provoking positions should decrease response and improve tolerance (Eleftheriadou et al., 2012).○ Habituation exercises are less effective but can be used when

repositioning treatments are contraindicated.

Intervention Strategies ● Substitution: To emphasize strategies that advantage the

visual and somatosensory system to “substitute” function for the vestibular system.

● Substitution uses visual and somatosensory cues to substitute the use of vision or proprioception for the use of vestibular input (Eleftheriadou et al., 2012).○ Used with patients that have complete bilateral vestibular hypofunction. ○ Strategies include the “Slow Blink”, use of AD.

(Umphred, 2013)

Clinical Practice Guideline: Posterior Canal BPPV● Canalith Repositioning Maneuvers:

○ Epley maneuver ○ Semont maneuver

(Bhattacharyya et al., 2008)

Semont Maneuver for Posterior BPPV

https://www.youtube.com/watch?v=z2KUrQoZ-sU

Clinical Practice Guideline: Lateral Canal BPPV● Canalith Repositioning Maneuvers:

○ The BBQ Roll■ Effectiveness of the roll maneuver in treating lateral canal BPPV

appears to be approximately 75 percent

○ Gufoni maneuver & Vannucchi-Asprella liberatory ● There is insufficient evidence to recommend

a preferred treatment maneuver for lateral canal BPPV treatment.

(Bhattacharyya et al., 2008)

Clinical Practice Guideline: Lateral Canal BPPV● Oron et al., 2015 reported that in lateral canal BPPV:

○ Geotropic nystagmus treated with the Gufoni maneuver is superior in its ease of performance compared with other maneuvers.

○ In the case of apogeotropic nystagmus, the Barbecue and Gufoni maneuvers have comparable success rates.

● Oron et al., 2015 reported that their confidence intervals for different treatments overlapped however.

● Take Home Point: It cannot be concluded from Oron et al.’s work that any treatment is better than another.

BBQ Maneuver for Horizontal BPPV

https://www.youtube.com/watch?v=FtLtpHbRSoE

Case Study: “Catherine”

(Wahlgren et al., 2012)

ReferencesBaloh R. W., (1998) Differentiating between peripheral and central causes of vertigo. Otolaryngology Head and Neck Surgery, 119, 55–59.

Bhattacharyya, N., Baugh, R. F., Orvidas, L., Barrs, D., Bronston, L. J., Cass, S., . . . Neck Surgery, F. (2008). Clinical practice guideline: benign paroxysmal positional vertigo. Otolaryngol Head Neck Surgery, 139(5 Suppl 4), S47-81. Bisdorff, A., Von Brevern, M., Lempert, T., & Newman-Toker, D. E. (2009). Classification of vestibular symptoms: towards an international classification of vestibular disorders. Journal of Vestibular Research, 19(1-2), 1-13. Büttner, U., C. H. Helmchen, and T. H. Brandt. "Diagnostic criteria for central versus peripheral positioning nystagmus and vertigo: a review." Acta oto-laryngologica 119.1 (1999): 1-5. Choung, Y. H., Shin, Y. R., Kahng, H., Park, K., & Choi, S. J. (2006). 'Bow and lean test' to determine the affected ear of horizontal canal benign paroxysmal positional vertigo. Laryngoscope, 116(10), 1776-1781.

ReferencesEleftheriadou, A., Skalidi, N., & Velegrakis, G. A. (2012). Vestibular rehabilitation strategies and factors that affect the outcome. Eur Arch Otorhinolaryngol, 269(11), 2309-2316. Kisner, C., Colby, L. A. (2012). Therapeutic Exercise (6th Edition.) F.A. Davis Company. Lee, J. B., Han, D. H., Choi, S. J., Park, K., Park, H. Y., Sohn, I. K., & Choung, Y. H. (2010). Efficacy of the "bow and lean test" for the management of horizontal canal benign paroxysmal positional vertigo. Laryngoscope, 120(11), 2339-2346. Oron, Y., Cohen-Atsmoni, S., Len, A., & Roth, Y. (2015). Treatment of horizontal canal BPPV: pathophysiology, available maneuvers, and recommended treatment. Laryngoscope, 125(8), 1959-1964. Umphred, D. et al (2013) Neurological Rehabilitation. (6th Edition) Elsevier. Wahlgren, A., & Palombaro, K. (2012). Evidence-based physical therapy for BPPV using the International Classification of Functioning, Disability and Health model: a case report. J Geriatr Phys Ther, 35(4), 200-205.